Human factors: Learning organisations
A learning organisation not only values and encourages learning from its own experiences, but looks beyond itself for lessons, and avoids complacency. This is one of the 7 key elements identified by HSE in improving safety management, leadership and safety culture. Near misses, incidents, accidents should be thoroughly investigated by those trained in investigation techniques. Perhaps more importantly, the lessons learnt from such investigations should be communicated widely and recommendations implemented swiftly. In an organisation that does not learn, incident investigations highlight a failure to implement earlier recommendations.
The distinction between passive learning (where lessons are identified but not put into practice) and active learning (where those lessons are embedded into an organisation's culture and practices) is crucial in understanding why truly effective learning so often fails to take place. Learning is linked to 'corporate memory', which must withstand staffing losses and changes, including contractorisation.
Learning organisations are characterised by 'chronic unease', for example, they actively seek out information even in areas that appear to be running smoothly. They also 'amplify weak signals' - straining to hear and learn from apparently weak signals, eg from the frontline.
Barriers to organisational learning include:
- An undue focus on the immediate event rather than on the root causes of problems;
- Latching onto one superficial cause or learning point;
- Failure to address the issues of blame, accountability, responsibility and discipline;
- A culture of individual 'error' rather than one that takes a systems approach;
- 'Scapegoating' rather than addressing deep-rooted organisational problems;
- Changes among key personnel within organisations and teams;
- Ineffective communication and other information difficulties;
- Tackling small individual issues, rather than addressing more fundamental change;
- Pride in individual and organisational expertise leading to denial, and a disregard of external sources of lessons;
- Not listening to 'bad news' and a failure to challenge existing systems, procedures and structures;
- Inability to recognise the financial costs of failure, thus losing a powerful incentive for organisations to change.